Knowledge and Acceptance of COVID-19 Vaccination Among Undergraduate Students from Central and Southern Italy

Article Knowledge and Acceptance of COVID-19 Vaccination among Undergraduate Students from Central and Southern Italy

Francesca Gallè 1,* , Elita Anna Sabella 2, Paolo Roma 3 , Osvalda De Giglio 4 , Giuseppina Caggiano 4 , Silvio Tafuri 4 , Giovanna Da Molin 2, Stefano Ferracuti 3 , Maria Teresa Montagna 4 , Giorgio Liguori 1, Giovanni Battista Orsi 5 and Christian Napoli 6

1 Department of Movement Sciences and Wellbeing, University of Naples “Parthenope”, 80133 Naples, Italy; [email protected] 2 Inter-University Research Centre “Population, Environment and Health”, University of Bari Aldo Moro, 70121 Bari, Italy; [email protected] (E.A.S.); [email protected] (G.D.M.) 3 Department of Human Neurosciences, “Sapienza” University of Rome, 00185 Rome, Italy; [email protected] (P.R.); [email protected] (S.F.) 4 Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, 70124 Bari, Italy; [email protected] (O.D.G.); [email protected] (G.C.); [email protected] (S.T.); [email protected] (M.T.M.) 5 Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; [email protected] 6 Department of Medical Surgical Sciences and Translational Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; [email protected] * Correspondence: [email protected] Citation: Gallè, F.; Sabella, E.A.; Roma, P.; De Giglio, O.; Caggiano, G.; Abstract: At the end of 2020, the Italian Ministry of Health launched a national vaccination campaign Tafuri, S.; Da Molin, G.; Ferracuti, S.; to counteract the COVID-19 pandemic. The present study aimed at appraising levels of knowledge Montagna, M.T.; Liguori, G.; et al. about and acceptance of COVID-19 vaccination in a sample of Italian undergraduates during the first Knowledge and Acceptance of phase of the immunization plan. A web-based questionnaire was administered to students attending COVID-19 Vaccination among universities in Bari, Naples, and Rome during the period February–April 2021. Of the total of 3226 Undergraduate Students from Central participants, 91.9% were keen to receive a COVID-19 vaccination. More than 80% gave correct answers and Southern Italy. Vaccines 2021, 9, 638. https://doi.org/10.3390/ to questions about COVID-19 vaccine administration, functioning, and effects on community health. vaccines9060638 However, only 63.8% identified the correct composition of the available vaccines. Knowledge was found to be related to sociodemographic features and COVID-19 vaccination acceptance (p < 0.05). Academic Editors: Chiara de Waure, COVID-19 vaccination acceptance was found to be related to having a previous vaccination against Aldo Rosano and Chiara Cadeddu influenza (OR 3.806, CI 95% 1.181–12.267; p = 0.025) and knowledge (OR 4.759, CI 95% 2.106– 10.753; p = 0.000). These results show a good level of awareness about COVID-19 vaccination in this Received: 24 May 2021 population, which may indicate the effectiveness of communication strategies accompanying the Accepted: 8 June 2021 COVID-19 immunization campaign in Italy. Published: 10 June 2021 Keywords: SARS-COV-2; COVID-19; vaccine hesitancy; vaccine acceptance; information; undergraduates Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. 1. Introduction Coronavirus disease 2019 (COVID-19) is a severe acute respiratory disease (SARS) caused by the novel coronavirus (SARS-COV-2) first detected in Wuhan, China, at the end of 2019 [1]. Since its onset, SARS-COV-2 has spread rapidly throughout the world [2], Copyright: © 2021 by the authors. having a significant impact on healthcare services and workers [3]. Currently, the COVID- Licensee MDPI, Basel, Switzerland. 19 pandemic has registered approximately 154 million cases and more than 3 million This article is an open access article deaths [2]. Due to this social and healthcare burden, countries have adopted several distributed under the terms and conditions of the Creative Commons strategies to control the spread of the virus, including social distancing, suspension or Attribution (CC BY) license (https:// modification of working activities, restricted movement, and obligatory use of facial creativecommons.org/licenses/by/ masks [4]. Although necessary, these measures have had indirect negative consequences on 4.0/).

Vaccines 2021, 9, 638. https://doi.org/10.3390/vaccines9060638 https://www.mdpi.com/journal/vaccines Vaccines 2021, 9, 638 2 of 13

national economies and personal health, leading to a rise in mental disorders and unhealthy behaviors [5–10]. In 2020, efforts were made across the world to rapidly develop vaccines for COVID- 19 [11]. In this process, scientific and medical communities worked together with gov- ernmental institutions, with the result that several effective vaccines were approved in record time [11,12]. At the end of 2020, the Italian Ministry of Health launched the strategic immunization plan, aimed at achieving herd immunity in the Italian population [13–15]. Health and teaching personnel, police forces, and elderly and vulnerable people were prioritized for vaccinations [13–15]. At the beginning of 2021, three vaccines began to be administered in Italy: the mRNA vaccines Moderna (by Moderna Biotech) and Comirnaty (by Pfizer/BioNTech), and the viral vector vaccine Vaxzevria (by AstraZeneca) [13–15]. Since that time, the effort to achieve herd immunity throughout the Italian territory has in- volved a notable economic and organizational effort by Italian institutions and authorities. However, as vaccination is voluntary, popular acceptance represents a key factor. Vaccine hesitancy, which consists of a delay in acceptance or a refusal of vaccination despite the availability of vaccination services [16], may compromise the success of any immunization campaign. This is particularly critical in Italy, where, over the last decade, vaccine hesitancy movements have led to a growing mistrust of vaccines and a subsequent decline in vaccination coverage rates, forcing the Italian Ministry of Health to increase the number of mandatory infant vaccines [17]. Furthermore, both the accelerated development of the COVID-19 vaccines [18] and the novel formulation of some of these vaccines [19] may have contributed to increasing vaccine hesitancy. On March 15 2021, the Italian Drug Agency (Agenzia Italiana del Farmaco (AIFA)) decreed the precautionary suspension of the Vaxzevria vaccine following some cases of thrombosis registered worldwide and in Italy [20]. While this suspension was revoked three days later [21], the event may have nonetheless increased vaccine hesitancy. Recent studies have underlined that different vaccine sentiments may create pockets of unvaccinated subjects, even in large communities of vaccinated people [22]. This represents a critical issue for public health management, as it can increase the risk for vulnerable individuals living within these unvaccinated pockets. Since vaccine hesitancy strictly relates to level of knowledge and sources of information, it is important to measure vaccine acceptance among various segments of the population in order to develop effective communication strategies against misinforma- tion [19,23]. Furthermore, age seems to play an important role in determining vaccine acceptance, with contrasting effects in different countries [18]. Therefore, the analysis of vaccine acceptance and its predictors in different age classes may be helpful for identifying hesitant groups and addressing their specific fears and concerns. With respect to Italian young adults, a study performed by Barello et al. in 2020, prior to the national immunization campaign, reported a preliminary intention to be vaccinated against COVID-19 in 86.1% of the sample [24]. In order to analyze the evolution of vaccine hesitancy in this target population, the present study aimed at appraising knowledge about and acceptance of COVID-19 vaccination in a sample of Italian undergraduates during the first phase of the national immunization campaign.

2. Materials and Methods 2.1. Setting and Participants This cross-sectional study was conducted in the period from February to April 2021. Participants were Italian undergraduate students attending three Italian universities in Rome, Naples, and Bari, respectively. During the study period, the selected universities were providing lessons via the Internet due to the control measures in place during the second wave of the COVID-19 pandemic. Students were invited during remote lessons to voluntarily participate in the survey by responding to an online questionnaire. The survey was carried out simultaneously in the three universities. Vaccines 2021, 9, 638 3 of 13

In total, the three universities had 158,462 students in the target population of undergraduates; thus, a sample of at least 384 individuals was required to explore the selected variables, assuming a response rate of 50%, a 95% conﬁdence level, and a 5% margin of error, as discussed in previous studies [6,7]. The study was performed in accordance with the World Medical Association Declara- tion of Helsinki. Participants were guaranteed the anonymity of the collected information. The Scientiﬁc and Ethical Institutional Board of the Italian Inter University Research Centre “Population, environment and health” (CIRPAS) approved the protocol (approval number 2101_2021).

2.2. Questionnaire The survey was comprised of an original questionnaire written in the Italian language and administered using SurveyMonkey. The questionnaire included three sections. The first section aimed at collecting sociodemographic information (i.e., gender, age, university, degree course, parents’ educational level, whether or not they were a healthcare worker) and personal experience of COVID-19 (personal infection/infection of a relative; infection that was asymptomatic/symptomatic/severe). These items were designed on the basis of a previous study with the same student population [6] and the advice of a panel of experts comprised of one demographer, one epidemiologist, and one psychologist. The second section of the questionnaire investigated respondents’ general acceptance of vaccination and specific acceptance of the COVID-19 vaccine. This section was modeled on the questionnaire used by Sallam et al. [25], which was adapted to the Italian context. The modified items were drafted by a panel of experts comprised of two epidemiologists, one expert in public health, and one psychologist. Respondents were asked to declare if they were favorable to vaccinations in general (yes/no/I don’t know), if they had been immunized against the influenza virus in 2019/20 and/or 2020/21 (yes/no), if they had received at least a single dose of the COVID-19 vaccine (yes/no), and if they were willing to be vaccinated against COVID-19 (yes/no/I don’t know). A further question was posed to those who declared their unwillingness to be vaccinated in order to obtain their main motivations for this position (I don’t trust vaccines/these vaccines are not effective/I’m allergic/I’ve had the disease/I’m not at risk). The third section aimed at assessing respondents’ knowledge, opinions, and sources of information about the COVID-19 vaccines. This section was based on available data regarding COVID-19 vaccination issues and vaccination hesitancy [11,12,25], as well as statements issued by national institutions [13]. Items in this section were drafted by a panel of experts comprised of one epidemiologist, one expert in vaccinology, and one psychologist. The items investigated in this section are reported in the Supplementary Materials (File S1). Prior to its administration in the present study, the questionnaire was tested in a pilot study (data neither published nor included in this paper). Overall, 144 students were enrolled for this preliminary study. In order to evaluate the comprehensibility of the questions, students were asked to assign a score to each question on a seven-point scale ranging from 1 (not meaningful) to 7 (very meaningful). Moreover, as discussed in previous studies [6,7], in order to guarantee variability in the answers for the pilot study, 12 further questions (FQs) including errors (grammatical and/or semantic) were added to the original questionnaire questions (OQs). The OQs resulted in a mean score for each question of ≥6 (almost the maximum); the FQs produced a mean score of <2. These data confirmed that the content of the questionnaire was clear. The reliability index was assessed for both the pilot and the original questionnaire using Cronbach’s alpha (internal consistency coefficient) [26,27]. The alpha values were 0.83 and 0.79, respectively, showing a satisfactory level of reliability [28]. Vaccines 2021, 9, 638 4 of 13

2.3. Statistical Analyses A descriptive analysis was performed on participants’ demographic characteristics and examined experience, acceptance, knowledge, and opinions about COVID-19 vaccination. Age was expressed as a mean value ± standard deviation (SD). Other characteristics and answers were reported as numbers and percentages of respondents. Influenza vaccination rates reported for the seasons 2019/20 and 2020/21 and answers regarding willingness to be vaccinated and consequences of COVID-19 vaccination on health, registered be- fore and after the suspension of Vaxzevria on March 15 2021, were compared using a chi-squared test. Differences in vaccine acceptance among the three university groups were analyzed through the chi-squared test. Level of knowledge was expressed as the total number of correct answers (range 0–11). The median and the interquartile range were calculated for knowledge. The median number of correct answers from the three participant universities was compared through the Kruskal–Wallis test. A Spearman correlation analysis was conducted to highlight possible relationships between the level of knowledge of participants and variables related to their sociodemographic characteristics and vaccine acceptance. A logistic regression analysis was performed to investigate the possible role of sample characteristics and knowledge about vaccination in determining COVID-19 vaccine acceptance. In particular, gender (expressed as male = 0; female = 1), age (lower or equal to median value = 0; higher than median value = 1), area of study (other = 0; life science = 1), parents’ educational level (elementary/middle school = 0; high school = 1; degree/post-degree = 2), whether or not the participant was a healthcare worker (no = 0; yes = 1), personal experience of COVID-19 (no = 0; yes = 1), and level of knowledge (number of correct answers lower or equal to median value = 0; higher than median value = 1) were considered as independent variables. Vaccine acceptance was considered as the dependent variable, with a value of 0 attributed to respondents who had not yet been vaccinated against COVID-19 and were not willing to be immunized and a value of 1 attributed to those who had been vaccinated or were favorable to vaccination. A preliminary univariate analysis was performed to detect variables significantly associated with vaccine acceptance; subsequently, these variables were included in the logistic regression analysis. Results were expressed as odds ratios (ORs) with a corresponding 95% confidence interval (95% CI). A p-value of 0.05 was assumed as a significance level. The software IBM SPSS version 27 for Windows (IBM Corp., Armonk, NY, USA) was used for all analyses.

3. Results A total of 3226 students completed the questionnaire in full. Table1 shows the sociodemographic characteristics of the sample.

Table 1. Sample characteristics.

Participants Variable n = 3226 Age, years Mean ± SD 23.3 ± 3.9 Range 18–45 Median value 22 Interquartile range 21–25 Gender, n (%) Male 1421 (44) Female 1805 (56) Father‘s educational level, n (%) Elementary/middle school 846 (26.2) High school 1596 (49.5) Degree/post-degree 784 (24.3) Vaccines 2021, 9, 638 5 of 13

Table 1. Cont.

Participants Variable n = 3226 Mother‘s educational level, n (%) Elementary/middle school 755 (23.4) High school 1603 (49.7) Degree/post-degree 868 (26.9) Area of study, n (%) Life science 1787 (55.4) Other 1439 (44.6) Healthcare worker, n (%) Yes 264 (8.2) No 2962 (91.8) COVID-19 infection, n (%) Yes 299 (9.3) Asymptomatic 72 (24.1) Symptomatic 219 (73.2) Severe 8 (2.7) No 2927 (90.7) COVID-19 infection in relative, n (%) Yes 947 (29.4) Asymptomatic 143 (15.1) Symptomatic 602 (63.6) Severe 132 (13.9) Dead 70 (7.4) No 2279 (70.6)

The majority of the sample was composed of females and students attending a life science course, and mainly a high school educational level was reported for both parents. A small proportion of participants (8.2%) were healthcare workers. The great majority of the sample had not been infected with COVID-19, while approximately 30% reported an infected relative. For these relatives, a symptomatic form of the disease was mainly reported. Table2 presents participants’ expressed acceptance of vaccination, in general, and COVID-19 vaccination, in particular.

Table 2. Participants’ acceptance of general vaccination and COVID-19 vaccination.

Respondents Question n = 3226 Favorable to vaccination, n (%) Yes 3012 (93.4) No 115 (3.6) I don’t know 99 (3.1) Vaccinated against inﬂuenza (2019/20 season), n (%) Yes 515 (16) No 2711 (84) Vaccinated against inﬂuenza (2020/21 season), n (%) Yes 1244 (38.6) No 1982 (61.4) Vaccines 2021, 9, 638 6 of 13

Table 2. Cont.

Respondents Question n = 3226 Vaccinated against COVID-19, n (%) Yes 375 (11.6) No 2851 (88.4) Willing to be vaccinated against COVID-19, n (%) Yes 2621 (91.9) No 55 (1.9) I don’t know 175 (6.1)

Nearly all participants were favorable to vaccination in general. Although the majority of the sample had not been vaccinated against influenza (during the prior two seasons) or COVID-19, more than 90% declared their willingness to be vaccinated against COVID-19. Interestingly, the proportion of students who had been immunized against influenza more than doubled in 2020/21 relative to the previous season, and the difference in vaccination between the two seasons was statistically significant (p < 0.001). Table3 presents participants’ knowledge and opinions about COVID-19 vaccination.

Table 3. Participants’ knowledge and opinions about COVID-19 vaccination.

Respondents Question n = 3226 The available COVID-19 vaccines contain: The coronavirus 122 (3.8) A virus similar to coronavirus 53 (1.6) The antigens of the virus (the protein “spike”) 994 (30.8) The genetic information to build the antigen “spike” 2057 (63.8) The available COVID-19 vaccines are administered: In a single dose 60 (1.9) In two doses 3095 (95.9) In two doses only for those subjects who are not 71 (2.2) immunized with the ﬁrst administration Do you think that inﬂuenza vaccination may protect against COVID-19? n (%) Yes 707 (21.9) No 2519 (78.1) Do you think that the COVID-19 vaccines are effective in preventing COVID-19 infection? n (%) Yes 2598 (80.5) No 628 (19.5) Do you think that the COVID-19 vaccines may reduce symptoms of COVID-19? n (%) Yes 2527 (78.3) No 699 (21.7) Do you think that the COVID-19 vaccines cause the disease in order to trigger immunity? n (%) Yes 626 (19.4) No 2600 (80.6) Vaccines 2021, 9, 638 7 of 13

Table 3. Cont.

Respondents Question n = 3226 Do you think that the COVID-19 vaccines modify the DNA of vaccinated subjects? n (%) Yes 316 (9.8) No 2910 (90.2) Do you think that people vaccinated against COVID-19 can avoid other prevention measures, such as facial masks? n (%) Yes 119 (3.7) No 3107 (96.3) Do you think that all of the Italian population need to be vaccinated against COVID-19? n (%) Yes 2015 (62.5) No 1211 (37.5) Do you think that only health personnel and elderly people need to be vaccinated against COVID-19? n (%) Yes 112 (3.5) No 3114 (96.5) Do you think that “herd immunity” will be reached in Italy when all health personnel and elderly people are vaccinated against COVID-19? n (%) Yes 231 (7.2) No 2995 (92.8) In your opinion, might the COVID-19 vaccines cause health problems? n (%) Yes 1514 (46.9) No 1712 (53.1) In your opinion, might the COVID-19 vaccines negatively impact on individual privacy? n (%) Yes 159 (4.9) No 3067 (95.1) In your opinion, should COVID-19 vaccination become mandatory? n (%) Yes 1921 (59.5) No 1305 (40.5) What are your main sources of information about COVID-19 vaccination? n (%) Healthcare personnel, scientists 1434 (44.5) Mass media (i.e., television, general interest 1503 (46.6) magazines) Social media (i.e., Facebook, Twitter, Instagram, 268 (8.3) WhatsApp) YouTube or similar web channel 21 (0.7)

With respect to the characteristics of the available COVID-19 vaccines, approximately 64% of the sample knew that they contained the genetic information for viral antigen production, and approximately 96% were aware that they should be administered in two doses. Roughly 80% answered correctly that the inﬂuenza vaccine does not prevent COVID-19; that the COVID-19 vaccines may prevent and do not cause the disease, may reduce symptoms, and do not act through human DNA modiﬁcation; that COVID-19 vaccination does not negate the need to engage in other prevention measures; that the COVID-19 vaccines should not only be offered to elderly people and healthcare personnel; and that herd immunity will not be reached through only the immunization of these latter Vaccines 2021, 9, 638 8 of 13

populations. Finally, 62.5% thought that all of the Italian population need to be vaccinated against COVID-19, and 59.5% felt that COVID-19 vaccination should be compulsory. The median number of correct answers for the whole sample was 9 (interquartile range 8–10). Vaccines 2021, 9, x FOR PEER REVIEW 8 of 13 Approximately half of the sample perceived that the COVID-19 vaccines might cause some health effects, while more than 95% did not consider vaccination a risk to privacy. A signiﬁcant increase (from 24.3% to 69.7%, p < 0.001) in positive answers to the question regardingregarding the the health health consequences consequences of of the the COVID-19 COVID-19 vaccinesvaccines waswas registeredregistered afterafter thethe sus-sus- pensionpension of of Vaxzevria. Vaxzevria. Nonetheless, Nonetheless, this this event event did did not not impact impact on on respondents’ respondents’ willingness willingness toto be be vaccinated, vaccinated, which which showed showed a a signiﬁcant significant increase increase (from (from 88.8% 88.8% to to 95.2%, 95.2%,p p< < 0.001). 0.001). HealthcareHealthcare personnel/scientists personnel/scientists and and the the mass mass media media were reportedwere reported as the mainas the sources main ofsources information. of information. AsAs for for the the comparison comparison among among the the three three universities, universities, Figure Figure1 1shows shows the the proportions proportions ofof studentsstudents vaccinated/keen vaccinated/keen to bebe vaccinatedvaccinated andand thethe medianmedian levellevel ofof knowledgeknowledge in in the the threethree undergraduate undergraduate groups. groups. Median number of correct answers Median number 100 12 90 80 10 70 8 60 50 6 40 30 4 % of respondents % of 20 2 10 0 0 Bari Naples Rome

Not vaccinated/Not keen to vaccination Vaccinated/Keen to vaccination

Knowledge level

FigureFigure 1. 1. Acceptance (percentage (percentage of of students students vaccinate vaccinated/keend/keen to be to bevaccinated) vaccinated) and and knowledge knowledge (me- (mediandian number number of correct of correct answers) answers) regarding regarding COVID- COVID-1919 vaccination vaccination in in the the three three participant participant universi- univer- ties sities.

BothBoth the the acceptance acceptance of of COVID-19 COVID-19 vaccination vaccination and and the the level level of of knowledge knowledge were were lower lower inin participants participants attendingattending thethe University University ofof Naples Naples than than in in the the other other groups. groups. Both Both these these differencesdifferences were were signiﬁcant significant ( p(p< < 0.001). 0.001). TableTable4 4shows shows the the results results of of the the correlation correlation analysis analysis performed performed on on the the variables. variables.

TableTable 4. 4.Results Resultsof ofthe the correlationcorrelation analysisanalysis betweenbetween knowledge about COVID-19 vaccination vaccination and and otherother variables. variables. Spearman’s Correlation Coefficient Spearman’s Correlation Coefﬁcient Variable pp--ValueValue 0.2710.271 AgeAge 0.0000.000 −−0.1600.160 GenderGender 0.0000.000 0.1780.178 Father‘sFather‘s educationaleducational level level 0.0000.000 0.203 Mother‘s educational level 0.000 0.228 Area of study 0.000 0.036 Healthcare worker 0.039 COVID-19 infection −0.072

Vaccines 2021, 9, 638 9 of 13

Table 4. Cont.

Spearman’s Correlation Coefﬁcient Variable p-Value 0.203 Mother‘s educational level 0.000 0.228 Area of study 0.000 0.036 Healthcare worker 0.039 −0.072 COVID-19 infection 0.000 −0.070 COVID-19 infection in relative 0.000 Vaccinated/keen to be vaccinated against 0.079 COVID-19 0.000

A significant correlation with knowledge level was found for all of the considered variables; in particular, age, parents’ educational level, attending a life science course, being a healthcare worker, and being vaccinated or keen to be vaccinated against COVID-19 were positively correlated with knowledge. On the contrary, female gender and previous experience of COVID-19 were negatively correlated with knowledge. Table5 reports the results of the logistic regression analyses performed including only those independent variables that were significantly associated with vaccine acceptance in the univariate analysis: age class (lower than or equal to/higher than the median value of 22 years), gender (male/female), previous influenza vaccination (no/yes), and level of knowledge about COVID-19 vaccination (number of correct answers lower than or equal to/higher than the median value of 9).

Table 5. Results of the logistic regression model built considering the acceptance of COVID-19 vaccination as the outcome.

Vaccine Acceptance Independent Variable OR (CI 95%) Age ≤22 years Reference ≥23 years 0.774 (0.447−1.341) Gender Male Reference Female 0.597 (0.329–1.083) Vaccinated against inﬂuenza (season 2019/20) No Reference Yes 3.806 (1.181–12.267) * Level of knowledge about COVID-19 vaccines ≤9 correct answers Reference ≥10 correct answers 4.759 (2.106–10.753) ** OR (CI 95%): odds ratio (95% conﬁdence interval); * p < 0.05; ** p < 0.01.

Being vaccinated against inﬂuenza in 2019/20 (p = 0.025) and a higher level of knowledge (p = 0.000) were found to be associated with being vaccinated/keen to be vaccinated against COVID-19.

4. Discussion The present study aimed at assessing knowledge and acceptance of COVID-19 vaccination among Italian undergraduates. The results show a high level of acceptance towards COVID-19 vaccination and a good level of knowledge regarding the vaccine characteristics Vaccines 2021, 9, 638 10 of 13

and immunization campaign in this population group. Moreover, knowledge and vaccine acceptance were found to be correlated. With respect to knowledge, the only critical issue was registered with regard to the formulation of the available vaccines. However, it should be noted that approximately 45% of the sample was comprised of students attending courses outside of the life sciences, and this may have determined their incomplete comprehension of how the new vaccines work. As for the perception of negative health consequences from the vaccines, this increased significantly after the precautionary suspension of Vaxzevria. At the same time, surprisingly, acceptance of COVID-19 vaccination also increased significantly. A potential explanation for this is that the sample was more worried about COVID-19 than a possible adverse effect of vaccination. Such an attitude might have been determined by the sources of information consulted: fewer than 10% of respondents acquired information from uncontrolled sources (social media, web channel, etc.). Greater knowledge about COVID-19 vaccination was related to older age, male gender, higher educational level of parents, being a healthcare worker, attending a life science course, and acceptance of COVID-19 vaccination. On the contrary, female gender and direct experience with the disease were inversely related to vaccine knowledge. The finding related to gender contrasts with previous findings of better knowledge among female students [6]; this is likely due to the higher male/female ratio in the present study, denoting a better sample distribution by gender. The proportion of respondents willing to receive COVID-19 vaccination (91.9%) was higher than that registered in another Italian region (Emilia Romagna) by Reno et al. in January 2021 (68.9%) [29] and by Barello et al., who reported a low intention to vaccinate (vaccine hesitancy) among 13.9% of their interviewed students [24]. However, the present finding is in line with the 91% vaccine acceptance reported by Biasio et al. in their study performed during the same months on a sample of Italian adults [30]. Notably, in the present study, the high acceptance of COVID-19 vaccination was not influenced by knowledge regarding vaccine effectiveness: only 80% of the sample thought that the vaccine was effective in preventing the disease. Regardless, the sample considered the vaccine helpful in reducing the chance of infection. In Barello et al.’s study, no differences in vaccine acceptance were found between students attending healthcare and non-healthcare degree courses [24]. On the contrary, the present study found greater knowledge about COVID-19 and greater willingness to receive the vaccine among life science undergraduates, as also demonstrated in a previous study [6]. This finding is notable considering the potential risks linked to healthcare students’ vaccine hesitancy: vaccination of healthcare workers and students is a key measure in the prevention of healthcare-associated COVID-19 infections due to the close contact of these populations with high-risk patients. For this reason, public health information cam- paigns should aim at raising awareness of the crucial role of individual control measures, such as vaccination, in safeguarding individual and community health [24]. Our analysis made it possible to highlight differences in the outcomes among the universities enrolled, with students from Naples showing lower acceptance and knowledge levels. This aspect should be further investigated in depth with a specific protocol targeted at analyzing possible differences related to locations. The regression analysis showed that both knowledge and vaccination against influenza in 2019/20 were related to vaccine acceptance. This is consistent with findings from another study showing that prior vaccination against seasonal influenza predicted intention to be immunized against COVID-19 [31]. Notably, in the multivariable analysis, age and gender were not significantly associated with vaccine acceptance, though females were significantly less favorable to vaccination than males (97.7% vs. 98.8%, p = 0.016). This finding contrasts with the results of other studies showing a lower intention to be vaccinated against COVID-19 in women and younger adults [29,31–33]. The age range of our sample was potentially too narrow to detect age differences. Furthermore, personal infection with COVID-19 did not emerge Vaccines 2021, 9, 638 11 of 13

as a significant predictor of vaccine willingness and acceptance, as reported by Reno et al. [29]. Most likely, respondents who had already experienced the disease considered themselves immune against a new infection. In contrast, experience of a relative being infected with COVID-19 was inversely correlated with knowledge, suggesting that a low level of knowledge may have led respondents to ignore the control measures, thereby increasing their risk of contracting the disease. With regard to influenza vaccination, other authors have reported a similar percentage of vaccinated students (38.6%) [30]. Moreover, in the present study, the reported vaccination rate in 2020/21 was significantly higher than that of the previous season. This suggests that the COVID-19 pandemic may have increased attention to other SARS agents and raised respondents’ willingness to receive the influenza vaccine [34]. The present study has some limitations. First, knowledge could not be investigated in depth due to the need to avoid an excessive length of the questionnaire. This could have hidden important information regarding uncollected variables. Furthermore, the study population was enrolled by convenience sampling from three Italian universities; these students represent a specific population group and are not representative of the whole population of young adults in Italy. Moreover, it should also be taken into account that our sample only included undergraduates attending universities located in central and southern Italy, with the exclusion of northern ones. Considering the important differences in the socio-economic characteristics of northern, central, and southern areas in the Italian territory, and also the varying impact of the COVID-19 epidemic among these areas, a comparison with other undergraduate groups from northern regions would have been useful to detect possible geographical differences. However, the study offers a picture of vaccine acceptance and knowledge in a large sample of Italian undergraduates during the first phase of the COVID-19 immunization campaign. It confirms that knowledge and acceptance are strictly related, underlining the role of correct information in fighting vaccine hesitancy [19,23]. This issue should be continually monitored and characterized over time.

5. Conclusions Notwithstanding the enrollment of universities located only in central and southern Italy, our study found high knowledge and acceptance of COVID-19 vaccination among Italian undergraduates. This supports the effectiveness of the information strategy that has accompanied the COVID-19 immunization campaign in Italy. Nonetheless, the situation requires constant monitoring. Policy makers, government ofﬁcials, and the media should pay attention to the spread of data not supported by scientiﬁc evidence that may affect vaccine acceptance.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10 .3390/vaccines9060638/s1, Supplementary File 1 (S1): Questionnaire section regarding knowledge and opinions on COVID-19 vaccines. Author Contributions: Conceptualization: F.G., E.A.S., C.N.; methodology: F.G., E.A.S., C.N., G.D.M.; formal analysis: F.G., E.A.S., C.N.; investigation: F.G., E.A.S., P.R., C.N., G.D.M., O.D.G., G.L., S.F., M.T.M., S.T., G.C., G.B.O.; data curation: F.G., E.A.S., P.R., C.N., G.D.M., O.D.G., G.L., S.F., M.T.M., S.T., G.C., G.B.O.; writing—original draft preparation, F.G., E.A.S., C.N.; writing—review and editing: F.G., E.A.S., P.R., C.N., G.D.M., O.D.G., G.L., S.F., M.T.M., S.T., G.C., G.B.O. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki. It does not report experiments on humans or animals and it was approved by the Institutional Review Board of the Italian Inter Universities Research Centre “Population, environment and health” (CIRPAS) (protocol code 2101_2021, released on 4 February 2021). Vaccines 2021, 9, 638 12 of 13

Informed Consent Statement: Participation in this study was voluntary. Informed consent was ensured by the presence of an introductory section in the survey measure used, with the submission of responses implying an agreement to participate. Data Availability Statement: All data presented are available upon request from the corresponding author (F.G.). Acknowledgments: The authors would like to thank all the students who voluntary participated in the survey. Conﬂicts of Interest: The authors declare no conﬂict of interest.

References 1. World Health Organization Regional Office for Europe. Coronavirus disease (COVID-19) pandemic. Available online: https: //www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov (accessed on 5 May 2021). 2. World Health Organization. Coronavirus Disease (COVID-19) Dashboard. Available online: https://covid19.who.int/?gclid=Cj0 KCQiA-OeBBhDiARIsADyBcE7PVve11fZgyLj_kI8swygsjyQf8sMt-rAkiRRBbPgHo0VpON9KyPMaAkgfEALw_wcB (accessed on 5 May 2021). 3. Lahner, E.; Dilaghi, E.; Prestigiacomo, C.; Alessio, G.; Marcellini, L.; Simmaco, M.; Santino, I.; Orsi, G.B.; Anibaldi, P.; Marcolongo, A.; et al. Prevalence of Sars-Cov-2 infection in health workers (HWs) and diagnostic test performance: The experience of a teaching hospital in central Italy. Int. J. Environ. Res. Public Health 2020, 17, 4417. [CrossRef][PubMed] 4. Roma, P.; Monaro, M.; Muzi, L.; Colasanti, M.; Ricci, E.; Biondi, S.; Napoli, C.; Ferracuti, S.; Mazza, C. How to improve compliance with protective health measures during the COVID-19 outbreak: Testing a moderated mediation model and machine learning algorithms. Int. J. Environ. Res. Public Health 2020, 17, 7252. [CrossRef][PubMed] 5. Nicola, M.; Alsafi, Z.; Sohrabi, C.; Kerwan, A.; Al-Jabir, A.; Iosifidis, C.; Agha, M.; Agha, R. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int. J. Surgery 2020, 78, 185–193. [CrossRef][PubMed] 6. Gallè, F.; Sabella, E.A.; Da Molin, G.; De Giglio, O.; Caggiano, G.; Di Onofrio, V.; Ferracuti, S.; Montagna, M.T.; Liguori, G.; Orsi, G.B.; et al. Understanding knowledge and behaviors related to the COVID-19 epidemic in Italian undergraduate students: The EPICO Study. Int. J. Environ. Res. Public Health 2020, 17, 3481. [CrossRef][PubMed] 7. Gallè, F.; Sabella, E.A.; Ferracuti, S.; De Giglio, O.; Caggiano, G.; Protano, C.; Valeriani, F.; Parisi, E.A.; Valerio, G.; Liguori, G.; et al. Sedentary behaviors and physical activity of Italian undergraduate students during lockdown at the time of the COVID−19 pandemic. Int. J. Environ. Res. Public Health 2020, 17, 6171. [CrossRef] 8. Roma, P.; Monaro, M.; Colasanti, M.; Ricci, E.; Biondi, S.; Di Domenico, A.; Verrocchio, M.C.; Napoli, C.; Ferracuti, S.; Mazza, C. A 2-month follow-up study of psychological distress among Italian people during the COVID-19 lockdown. Int. J. Environ. Res. Public Health 2020, 17, 8180. [CrossRef] 9. Mazza, C.; Ricci, E.; Marchetti, D.; Fontanesi, L.; Di Giandomenico, S.; Verrocchio, M.C.; Roma, P. How Personality Relates to Distress in Parents during the Covid-19 Lockdown: The Mediating Role of Child’s Emotional and Behavioral Difficulties and the Moderating Effect of Living with Other People. Int. J. Environ. Res. Public Health 2020, 17, 6236. [CrossRef] 10. Robinson, E.; Boyland, E.; Chisholm, A.; Harrold, J.; Maloney, N.G.; Marty, L.; Mead, B.R.; Noonan, R.; Hardman, C.A. Obesity, eating behavior and physical activity during the COVID-19 lockdown: A study of UK adults. Appetite 2021, 156, 104853. [CrossRef] 11. García-Montero, C.; Fraile-Martínez, O.; Bravo, C.; Torres-Carranza, D.; Sanchez-Trujillo, L.; Gómez-Lahoz, A.M.; Guijarro, L.G.; García-Honduvilla, N.; Asúnsolo, A.; Bujan, J.; et al. An updated review of SARS-CoV-2 vaccines and the importance of effective vaccination programs in pandemic times. Vaccines 2021, 9, 433. [CrossRef] 12. Pai, S.M.; Othman, A.A.; Rusch, L.; Masters, J.C.; Greene, D.; Rogge, M.; Gries, J.; Clementi, W.; Kumar, P.; Younis, I.; et al. Science and evidence-based review and approval of COVID-19 vaccines: A statement of support for the US FDA. J. Clin. Pharmacol. 2021, 61, 277–279. [CrossRef] 13. Italian Ministry of Health. Vaccinazione anti-SARS-COV-2/COVID-19. Piano strategico. Available online: https: //www.trovanorme.salute.gov.it/norme/renderPdf.spring?seriegu=SG&datagu=24/03/2021&redaz=21A01802&artp= 1&art=1&subart=1&subart1=10&vers=1&prog=001 (accessed on 7 May 2021). 14. Italian Ministry of Health. Decreto 2/2/21 “Adozione del Piano strategico nazionale dei vaccini per la prevenzione delle infezioni da SARS-COV-2”. Available online: https://www.trovanorme.salute.gov.it/norme/renderNormsanPdf?anno=2021&codLeg=78 657&parte=1%20&serie=null (accessed on 7 May 2021). 15. Italian Ministry of Health. Circolare 24/12/20. Raccomandazioni per l’organizzazione della campagna vaccinale contro SARS-CoV-2/COVID-19 e procedure di vaccinazione. Available online: http://www.salute.gov.it/portale/nuovocoronavirus/ archivioNormativaNuovoCoronavirus.jsp?lingua=italiano&iPageNo=15 (accessed on 7 May 2021). 16. MacDonald, N.E. SAGE Working Group on Vaccine Hesitancy: Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015, 33, 4161–4164. [CrossRef] Vaccines 2021, 9, 638 13 of 13

17. Casula, M.; Toth, F. The 2017 Italian reform on mandatory childhood vaccinations: Analysis of the policy process and early implementation. Health Policy 2021, 125, 7–11. [CrossRef][PubMed] 18. Lazarus, J.V.; Ratzan, S.C.; Palayew, A.; Gostin, L.O.; Larson, H.J.; Rabin, K.; Kimball, S.; El-Mohandes, A. A Global Survey of Potential Acceptance of a COVID-19 Vaccine. Nat. Med. 2021, 27, 225–228. [CrossRef][PubMed] 19. Vaccination Hesitancy and the “myth” on mRNA-Based Vaccines in Italy in the COVID-19 era: Does Urgency Meet Major Safety Criteria? Available online: https://onlinelibrary.wiley.com/doi/10.1002/jmv.26922 (accessed on 8 June 2021). 20. Agenzia Italiana del Farmaco. Comunicato n. 637 del 15/03/21. AIFA: Sospensione precauzionale del vaccino AstraZeneca. Available online: https://www.aifa.gov.it/documents/20142/1289678/Comunicato_AIFA_637.pdf (accessed on 7 May 2021). 21. Agenzia Italiana del Farmaco. Comunicato n. 638 del 18/03/21. Dopo parere EMA, domani riprendono vaccinazioni con AstraZeneca. Available online: https://www.aifa.gov.it/documents/20142/1289678/Comunicato_AIFA_638.pdf (accessed on 7 May 2021). 22. Lazarus, J.V.; Wyka, K.; Rauh, L.; Rabin, K.; Ratzan, S.; Gostin, L.O.; Larson, H.J.; El-Mohandes, A. Hesitant or not? The association of age, gender, and education with potential acceptance of a COVID-19 vaccine: A country-level analysis. J. Health Comm. 2021, 25, 799–807. [CrossRef] 23. Charron, J.; Gautier, A.; Jestin, C. Influence of information sources on vaccine hesitancy and practices. Med. Mal. Infect. 2020, 50, 727–733. [CrossRef] 24. Barello, S.; Nania, T.; Dellafiore, F.; Graffigna, G.; Caruso, R. ‘Vaccine hesitancy’ among university students in Italy during the COVID-19 pandemic. Eur. J. Epidemiol. 2020, 35, 781–783. [CrossRef] 25. Sallam, M.; Dababseh, D.; Eid, H.; Al-Mahzoum, K.; Al-Haidar, A.; Taim, D.; Yaseen, A.; Ababneh, N.A.; Bakri, F.G.; Mahafzah, A. High rates of COVID-19 vaccine hesitancy and its association with conspiracy beliefs: A study in Jordan and Kuwait among other Arab countries. Vaccines 2021, 9, 42. [CrossRef] 26. Nunnally, J.C. Psychometric Theory, 2nd ed.; McGraw–Hill: New York, NY, USA, 1978; p. 144. 27. Kline, P. The Handbook of Psychological Testing, 2nd ed.; Routledge: London, UK, 1999; p. 627. 28. Taber, K.S. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res. Sci. Ed. 2018, 48, 1273–1296. [CrossRef] 29. Reno, C.; Maietti, E.; Fantini, M.P.; Savoia, E.; Manzoli, L.; Montalti, M.; Gori, D. Enhancing COVID-19 vaccine acceptance: Results from a survey on vaccine hesitancy in Northern Italy. Vaccines 2021, 9, 378. [CrossRef] 30. Biasio, L.R.; Bonaccorsi, G.; Lorini, C.; Mazzini, D.; Pecorelli, S. Italian adults’ likelihood of getting a COVID-19 vaccine: A second online survey. Vaccines 2021, 9, 268. [CrossRef] 31. Shmueli, L. Predicting intention to receive COVID-19 vaccine among the general population using the health belief model and the theory of planned behavior model. BMC Public Health 2021, 21, 804. [CrossRef][PubMed] 32. Paul, E.; Steptoe, A.; Fancourt, D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Regional Health Eur. 2021, 1, 100012. [CrossRef][PubMed] 33. Soares, P.; Rocha, J.V.; Moniz, M.; Gama, A.; Laires, P.A.; Pedro, A.R.; Dias, S.; Leite, A.; Nunes, C. Factors associated with COVID-19 vaccine hesitancy. Vaccines 2021, 9, 300. [CrossRef][PubMed] 34. Domnich, A.; Cambiaggi, M.; Vasco, A.; Maraniello, L.; Ansaldi, F.; Baldo, V.; Bonanni, P.; Calabrò, G.E.; Costantino, C.; de Waure, C.; et al. Attitudes and beliefs on influenza vaccination during the COVID-19 pandemic: Results from a representative Italian survey. Vaccines 2020, 8, 711. [CrossRef][PubMed]